HomeMy WebLinkAbout0643A WORKERS'COMPENSATION DECLARATION ppp��CATiON FOR �PERMIT �
I hereby affirm thaf I have a cerhficafe of consenf to self
insure,or a certifimte of Workers'Compensation Insu�ance, �y364C HEATING - VENTILATING - AIR CONDITtONING
or a certified copy rhereof(Sec.3800,Lab C) CE-Sis(aEV �0/87)
��y No. F �9 6 compony Fairmont Ins.
Cer�ified copy is here6y furnished COUNTY OF S.OS ANGELES BUILDING AND SAFETY
OCertified copy is filed wifh the county building inspec- FOR APPLICAN7 TO FILL IN H,;''���
fion depar/menL ADDRESS 24248 E. Doeskin Pl. Lot 32
�PRINT OR TYPE ONLYI
Date 5/29/&7 Applimnt Rz.ncho Air, Ir_c. ��ocnurv Bar CA Trac 3 k
NO TVPE OF APPLIANCE OR EQUIPMFNT FEE ,
CERTIFICA7EOFEXEMPiIC'."7C:Y :.'.;iY':�S'�� NEAREST
COMPENSATION '. .. ..,. CRO55 ST.
(This secfion need not be completed if}he work imolved by ABSORPTION UNIT,BTU o:STaicr n��0 PROCESSED B�
fhe permif is for one hundred dollars(5100)or less.)
I certify lhot in the performance of ihe work for which Ihis A�R HANDUNG UNI7,CFM �� /.y �
e.l
permif is issued,I shpll not employ any person m any manner BOILER.BTU
so as fo become subject to the Workers'Compensation Laws. A'PRo��n.s oar=. ,�s>e[roe�s5i�nnruee
�- COMFRESSOR,eTU 36aC�� �-� �� ROIiGH ✓`�r}a�yy�"..� �j' � "
,3�iP Applimnt
' TICE TO APPIICANT: If, af�er making ihis Certificate of vENTRqT�ON SYS7EM 1.� oo FiNa� "/�—LQ�
nxemption, you should become sub�ect �o the Worke�s'
Compensa�ion provisians of ihe LaFior Code,you musi forth- EVAPORATiVE CCOIER VALIDA710N
wdh camply with such provisions or this permit sholl be
deemed rgvoked. FURNACE FAU_GRgv TY
LICENSED CONTRACTORS DECIARATION 1 ROOR BiU bO��— -LO OO
I hereby affirm that I om licensed under provisions of Chapter 9 hEnieR SUSPeNDeo UNii_ �;��4'�fl
(commenang with Secfion 7000J of Division 3 of the Business � wALL
and Profess�ons Code,and my Lcense is in full force ond effecr � �c �,�,� p��,
Re i.ste'rs @ l. 19 25 }r R �
License N�mb�� 380543 u< CIb55 C-20 ► �F a�., �5 ta
04
con��a�ro� Ranchc Air,IriC.pa�e 8/37-/87 � ,,, �,� �
❑ I am exempt under Sec. � , ' �
Plcn check fee ��; y 4"'�� �
B.&P.C.for this reason
PERMI7 ISSUING FEE S 10 50 `
Date:
Signoture TOTAL FEE (1 75
OWNER-BUILDER DECLARATION PLAN CHECK APo�ICANT
I hereby affirm ihaf I om ezempt from the Contractor's License , '
L for the following reason(Section 7031 5, Busmess and NaME
!"""6essions Codep
,� I, as owne� of the property, or my employees wiih ADDRE55
wages as ihen sole compensahon,will da the work and C!TY TEL NO
ihe structure rs not mtended or offered for sale(Sedion
7044,Bus�ness and Professions Code1.
OWNER
❑ I,as owner of the property,om exdusrvely conirocting �
with Lcensed controcfors to wnsfruct the proled(Ser hM1AR
hon 7044.Business and Professions Code). ADDRE55 l Q 4 Pa-rkviez�r Drive �{201
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a<onstruction lending agency fo� CIiV OV1T12. TE� NO g6q_a5�,1 ,
1he perfarmance af the work for which this permn�s issued CONTRAQOR
�se�.aov�,c�v c�. Rancho �ir Irc.
AODRESS 1232 W. 9th St. �
Lender's Name
aTv II l�.nu TE� "o ggl-48o�
Lender's Address
STATE LIC
I cerlify lhaf I have read this applicafion and state thot fhe LICENSE NO �} CLA55 C-20
a6ove mformation is wrred I agree to mmply wiih all County
ordin and Siafe laws reloting lo buildmg construcnon,
and hereby au�honze represematives of ihis Counry to enfer -
upon th�gbove-meniion property f r mspecno ur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
/'/,�.�..–�, � �
S�q�a'ure of A�P��:cnt a�Age-.1 '�7a!e
eN3FEGYC9F&'�N�TE� C�JfvER-6UILGE�'D£CL/�^�ATIOPJ
� hereb/offirm fnat I am ex�mp;from t'na Coniwcior's
� canse La�.v for thc following �ea;en !Saclion 743i 5
' o snx;ss ann'Frufeesn.na Coc'o: .4ty a{or coo.^.ty vahrP
--' ' '---. . . .--'---�'--' rzqu�res o perm�f io wr.sir��ct,=Hcr,i:nproc�,demol;sh.
_ _ or repr.sr any sProcfure,prior to its issucnw, clso ro-
' ' qulres;na appllcant`o;such�ermit;o fila o signsd sSafe-
� ment ihat he i;liccnssd pursuant to h5e�ravisicns o£tna
ConFrcdcr's Licen�e Law!�.hop4cr 9(: , . }wnh
S�c:iors 7G�0�cr Diris=or.3 ef tha F'us'r.o s�cnd Pro'es�
" � s�cr.s Codej or tna'r he rs_.,.,n:pf,herefrom end Phe basis
tor 'rhe c!!egsd ^xa�rcuon F.ny viofatic� of Sac!ion.
7u31.5 by en�opplican4`or a permi9 subjects fFe apQL�
. cani to a civr!pertm4y nf not morc than iive hundr,�d
" � '^ d:;llors;Sa00;
L I.c_ ., -of��c a`aptr<y„iL do thz�m cna
, _-- tr.c� : ' o cs ro° � ' ' � sale. `r^.
� . . . . ;Se: !;i!�' 8�sines:.:.�, ., , . ....., � TheC� .ur
' � � , tor�s Gcensa LO�NCipG-5 not crply fo on owr,er o:prope-rfy
wbo bu�ids cr �rnpro. . ��; rc-on, and who does ;uch
� � v+ork h�:nself p:ovldedLthcieuch��,provem�Ms ore rot
�nlcrcad or oi{em6 for sele I!,bovserar,rha boiidirsg n�
' rmorovemen!is scid w+`bin onc�aor af complelicn,7h�
a�<mer-builder k�ill have the Surden of proving Ihc}Fe aid
� not 6uifd nr%mprovc fa'4he purpose�,f sal:.�.i '
_ ____ __ ❑I,as owr.er af the property,am exclusively cer��-
roct�r.y v:ith I! .sed c =_7o censlru<1'Fe r �;i
i,_ _____ _____ ISc:. ?0:;1 Business ano`nProfes,�ors.Cude 7fiz Cor�rac-
+cr's Licenso,a�m dces net cpplp.to on owner of proper;a
� _ _ r�ho'budds cr impreves thc-reon,ano wSo eonirac's ior
' ' such pro;'e-,7s wish a contractor(s)Ifccnsed pursoant io
fhe Cortrodor's:icer.sc taw?
t — —
I crr•ex^rnp���nder Sec_.___—_____.___
B&P.C.for Phis reason,_—_ ._
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